1. Northam, Sally PhD, RN


Sex, age, hierarchy, and culture influence the nursing environment.


Article Content

Conflict is common to all workplaces. But in nursing, studies have shown it's a particular source of job stress and dissatisfaction.1, 2 Among reasons for this is that nurses typically receive very little training in conflict management but are extensively trained in therapeutic communication.3 Over many years as a nurse and an educator, I've observed nurses using therapeutic communication methods in response to workplace conflict. Although this style of communication is useful in eliciting clinically relevant information from patients, among coworkers, it can lead to a focus on feelings and positions, rather than on solutions. The increasingly diverse health care workforce also contributes to tension for nurses. Sex, race and ethnicity, age, and perspectives on power have all been shown to influence how individuals perceive and respond to conflict.4


In this two-part series, I'll explore the factors contributing to workplace conflict and strategies to resolve it and build more effective-and harmonious-working relationships. Part 1 examines the often unrecognized influences of sex, age, power, and culture on workplace interactions, as well as individual responses to conflict. Part 2 will look at strategies for fostering collaborative and mutually respectful on-the-job relationships.



If conflict is common to most relationships, why should nurses be especially concerned? The answer emerges from studies of conflict in business settings and the impact of various conflict-management styles. Experts in conflict management view disagreement (conflict) as involving two opposing dimensions: assertiveness and cooperativeness 5 and a middle ground, compromise, where desired outcomes can be achieved.6 People respond to conflict in different ways within the two dimensions. Thomas and colleagues describe these responses as compromising, competing, avoiding, accommodating, or collaborating.7 Fowler and colleagues identify similar conflict resolution strategies but label them differently: withdrawal, force, conciliation, compromise, and confrontation.3 Compromise is generally regarded as the best way to resolve conflict because it reduces competition and avoidance without excessive accommodation or collaboration. However, studies have shown that nurses most often use withdrawal.


Although the terms used to discuss conflict management vary, experts agree that unresolved workplace conflict contributes to occupational stress, poor morale, job dissatisfaction, and turnover.8 This is especially so when conflict is managed by confrontation, avoidance, or withdrawal. Burnout is reduced when workers are able to resolve conflicts through compromise.2



How conflicts arise and how they are resolved have a great deal to do with the personalities of those involved. But there are other factors-often overlooked-that contribute to it or help to depersonalize it and lead to resolution. Those most applicable to nursing are culture, age or position in the organizational hierarchy, sex, and other workplace factors, such as schedules and workload.


Culture plays a large role in conflict resolution. For example, some Asian cultures emphasize respectful attention to the speaker or a superior, which can be misinterpreted as agreement or acquiescence. In a comparative study of Chinese and American business students, Friedman and colleagues found that when presented with conflict scenarios, Chinese students tended to follow orders from their managers or superiors rather than discuss the situation or offer suggestions.9 In an analysis of 14 studies of nurses from Asian countries, Xu found that misunderstandings, sometimes escalating to conflict, often stemmed from language and communication difficulties.10 Regardless of their fluency, the Asian nurses were ill-prepared for the shorthand and slang that permeate U.S. health care. Moreover, their cultural upbringing emphasized avoidance of conflict and preservation of harmony. A study of Japanese businesses found that although employees were expected to follow orders without question, supervisors had a corollary duty to look out for employees' welfare.11


Given the degree of diversity in today's health care workforce, cultural awareness is an important aspect of conflict resolution. In a study of culturally diverse workplace teams and their managers, Brett and colleagues identified four areas that potentially undermined the teams' effectiveness: "direct versus indirect communication; trouble with accents and fluency; differing attitudes toward hierarchy and authority; and conflicting norms for decision making."12 The authors gave several illustrations of cultural misunderstanding leading to conflict. In one, an expert consultant from Latin America became offended when an American team member took the lead in conversations because the consultant spoke English too slowly. In another, a manager of Mexican descent who posed questions instead of giving direct answers so as to demonstrate humility was regarded as indecisive. In a third example, workers from India clashed with their American counterparts over a software production timetable; the Americans emphasized speed and productivity while the Indians favored a slower, more cautious approach.


The researchers proposed four strategies for dealing with these challenges: "adaptation (acknowledging cultural gaps openly and working around them); structural intervention (changing the shape of the team); managerial intervention (setting norms early or bringing in a higher-level manager), and exit (removing a team member when other options fail)."12 The "work-around" adaptation is preferable because it empowers individuals involved in the conflict to resolve it, and allows for more innovative and mutually beneficial solutions than those imposed by managers or supervisors.13 The literature on theories of conflict management help only to a point; local knowledge and the shared experience of the group, however diverse, are vitally important assets in crafting lasting solutions.


Western cultural values also play a role in formulating approaches to resolving workplace conflict. For example, American managers generally believe that resolution is best achieved by avoiding blame and punishment, and deemphasizing the importance of determining the "truth."14 But these values may not be the norm for every member of a multicultural team, and some people might rather accept a state of ongoing conflict than attempt to resolve it.15


Age and hierarchy can influence conflict management and outcomes, especially when one person, or the other, sees deference as the proper role for the younger worker or subordinate. Much has been written about the impact of an individual's generation on workplace behavior. A recent study suggested greater benefits from multigenerational workforces, including opportunities for mentoring and contributions by individuals of varied backgrounds and experiences that collectively improve outcomes.16 But the study also found that younger workers tend to be more sensitive to generational issues, such as differences in technical skills, and are more likely to feel they aren't taken seriously by older coworkers. DiRomualdo suggested monitoring workplace generational issues, accentuating the positives and dealing with the negatives before they become problems.16 For example, if on-the-job cell phone use by younger staff or late arrival for nursing report spark tensions with older nurses, this should be discussed before it hardens into divisive conflict.


Sex. Many perspectives on conflict resolution have been authored by men-yielding a bias in how conflict and its resolution are understood.17 Even so, the results of inquiries into differences based on sex vary between studies. In a study of 114 business workers, Brewer and colleagues concluded that men were more likely to assert themselves in conflict, whereas women more often sought to avoid it.18 Another study, using undergraduate students as subjects, found that women were more likely than men to be collaborative in their approach to conflict resolution.19 These findings help to illuminate vulnerabilities in nursing, a profession where women make up the majority of the workforce, where conflicts may fester to the point of creating unhealthy work environments.


Workplace factors. Hospitals and other clinical workplaces tend to be governed by rules, which delineate what is right or permissible and what is wrong or banned. Those sharing a belief in what is right often view other beliefs as wrong-hence, the "right is right and wrong is wrong" attitude.20 This complicates conflict resolution, because what matters in disputes is not so much determining who is right but rather finding a middle ground that promotes understanding and leads to mutually acceptable solutions. Byford and others advocate listening with an open mind and assuming trustworthiness on everyone's part, even if beliefs are different.



Workplaces riddled with conflict are unhealthy and potentially undermining to even the most conscientious nurse. Workplace conflict was shown to be a factor in patient outcomes in a 1986 study of 5,020 patients in 13 hospitals; higher death rates correlated with higher levels of conflict between nurses and physicians.21 In 2004 the Joint Commission on Accreditation of Healthcare Organizations (now called the Joint Commission) reported that the majority of perinatal deaths and injuries were the result of problems with organizational culture and communication among caregivers.22 Also in 2004 the Institute for Safe Medication Practices (ISMP) linked workplace conflict to medication errors. The ISMP's survey of 2,000 health care professionals found that 40% sought to avoid conflict rather than take steps to resolve it.23 More recently, the Joint Commission issued a sentinel event alert on behaviors disruptive to patient safety, including unresolved workplace conflict, and noted the contribution to conflict of both intimidating and passive behaviors.24 The Joint Commission's 2007 National Patient Safety Goals include improving communication among caregivers.25 Communication failure remains the most frequently identified cause of all sentinel events reported to the Joint Commission.26


Unresolved conflict takes a toll on workers' physical and emotional health, as well as on relationships with their family.27 Recognizing this, many professional organizations have underscored the importance of effective conflict management in establishing standards for healthy work environments, including the American Nurses Association,28 the American Association of Colleges of Nursing,29 the American Organization of Nurse Executives (AONE),30 and the Accreditation Council for Graduate Medical Education.31 The American Association of Critical-Care Nurses devised six standards, including communication proficiency, which is the foundation of conflict management.32 The policy concludes:


Healthy work environments are essential to ensure patient safety, enhance staff recruitment and retention, and maintain an organizations' financial viability. Inattention to relationship issues poses a serious obstacle to creating and sustaining those environments. Without them, the journey to excellence is impossible.


Conflict resolution and clear communication can move from the establishment of healthy work environments standards to practice by "mapping a plan for cultural change in healthcare,"23 an idea shared by the Institute of Medicine.33 Six critical factors to creating healthy work environments identified by AONE include 30


* leadership development and effectiveness.


* empowered collaborative decision making.


* work design and service delivery innovation.


* values-driven organizational culture.


* recognition and reward systems.


* professional growth and accountability.


Heath and colleagues identified three elements necessary for healthy work environments: effective communication, collaborative relationships, and promotion of nurses' decision making.34 These elements are also the building blocks of a successful conflict resolution program. As a professional skill, astute management of conflict should be valued no less than cardiopulmonary resuscitation or other clinical capabilities.




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